Choosing the Correct Codes for Screening and Diagnostic Labs

Choosing the Correct Codes for Screening and Diagnostic Labs

Although Allscripts includes the Health Maintenance V70.0 code on all patients in the

EHR as a default, rarely is this code covered for lab orders by most payors. Below is

some information that can be helpful for choosing codes that are accepted by most

insurance plans.

? SCREENING is the testing for disease or disease precursors so that early detection and

treatment can be provided for those who test positive for the disease. Screening tests are

performed when no specific sign, symptom, or diagnosis is present and the patient has

not been exposed to a disease.

? Tests for screening purposes (i.e. labs) that are performed in the absence of signs,

symptoms, complaints, or personal history of disease or injury are typically NOT covered

by Medicare except as explicitly authorized by statute. These include exams required by

insurance companies, business establishments, government agencies, or other third

parties.?

TIP:

Do Your Research: Find out what screenings are covered

by statute.

For example, cardiovascular disease screenings for cholesterol,

lipid, and triglyceride levels is covered by Medicare Part B

(Medical Insurance) every 5 years. Search for ¡°Screen

Cardiovascular.¡± The code is V81.2.

?

? The testing of a person to rule out or to confirm a suspected diagnosis because the patient

has a sign and/or symptom is a DIAGNOSTIC test, NOT a screening. In these cases, the

sign or symptom should be used to explain the reason for the test.

? Any claim for a clinical diagnostic laboratory service must be submitted with an ICD-9-CM

diagnosis code. Codes that describe symptoms and signs, as opposed to a diagnosis,

should be provided for reporting purposes when a diagnosis has not been established by

the physician. (Based on Coding Clinic for ICD-9-CM, Fourth Quarter 1995, page 43).

TIP:

Always document (link) signs, symptoms, and

histories so that the diagnostic gets paid.

?

Diagnoses documented as ¡°probable,¡± ¡°suspected,¡± ¡°questionable,¡± ¡°rule-out,¡± or

¡°working diagnosis¡± should NOT be coded as though they exist. Rather, code the

condition(s) to the highest degree of certainty for that encounter/visit, such as

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signs, symptoms, abnormal test results, exposure to communicable disease or

other reasons for the visit. (From Coding Clinic for ICD-9-CM, Fourth Quarter

1995, page45).

TIP: Use Your Medical Training.

Document why you suspect the diagnosis

by linking signs and symptoms.

?

?

When the reason for performing a test is

because the patient has had contact with, or

exposure to, a communicable disease, the

appropriate code from category- ¡°V01, Contact

with or exposure to communicable diseases¡±should be assigned, not a screening code, but

the test may still be considered screening and

not covered by Medicare. For screening tests,

the appropriate ICD-9-CM screening code

from categories V28 or V73-V82 (or

comparable narrative) should be used. (From

Coding Clinic for ICD-9-CM, Fourth Quarter

1996, pages 50 and 52).

TIP:

Try searching

for ¡°exposed disease.¡±

When a non-specific ICD-9 code is submitted, the underlying sign, symptom, or

condition must be related to the indications for the test.

TIP

Search for the following codes when documenting signs and symptoms related to a suspected urinary

infection.

780.96

780.97

780.99

785.0

785.50-785.59

788.0-788.63, 788.64,

788.65, 788.69, 788.7788.8

788.99

Generalized pain

Altered mental status

Other general symptoms

Tachycardia, unspecified

Shock without mention of trauma

Symptoms involving urinary system (renal colic, dysuria, retention of urine,

incontinence of urine, frequency, polyuria, nocturia, oliguria, anuria, other

abnormality of urination, urethral discharge, extravasation of urine.)

Other symptoms involving urinary system

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Common Coverage Codes for Health Maintenance

Screening Procedures

Mammogram Screenings

Medicare covers screening mammography depending on the age of the woman:

Age

Frequency

Younger than age 35

No Medicare payment allowed

Aged 35 ¨C 39 years

Baseline (Medicare pays for only one

screening for women in this age group)

Aged 40 and older

Annual (at least 11 months after the last

covered screening mammograph

You must report one of the following ICD-9-CM screening (¡°V¡±) diagnosis codes, listed in

below for screening mammography:

Code

Description

Special screening for malignant neoplasms,

screening mammogram for high-risk patient

Special screening for malignant neoplasms,

other screening mammogram

V76.11

V76.12

Colonoscopy Screening

Screening Colonoscopies are performed on patients that have NO presenting signs or

symptoms related to the digestive system, but have reached the age for routine

screenings (age 50 for both men and women). Medicare covers one screening

colonoscopy every 10 years for individuals not considered high risk.

Code

V76.51

Description

Special screening for malignant

neoplasm, colon

TIP: Try searching for ¡°visit colon.¡±

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High Risk Codes (Medicare provides coverage of a screening colonoscopy once every

2 years for high risk.)

Code

V10.05

V12.72

V16.0

V10.06

Description

Personal history of malignant neoplasm, large

intestine

Personal history of colonic polyps

Family history of malignant neoplasm,

gastrointestinal tract

Personal history of malignant neoplasm of

rectum, rectosigmoid junction, and anus

You need to assess the actual medical necessity behind performing the

colonoscopy in the first place. It would not be medically necessary for an asymptomatic

average risk patient (V76.51) to be screened at a two, three, or five-year interval.

However, it might be medically necessary for an asymptomatic high-risk patient

(V12.72, V16.0, etc.) to be screened every two, three or five years, therefore the diagnosis

code used should reflect that.

Diagnostic Colonoscopy

When signs and symptoms are related to the GI tract (i.e., abdominal pain, blood in

stool, chronic diarrhea, change in bowel habits, weight loss or blood loss anemia), Vcode (V76.51) should never be assigned. A symptom code should be assigned

when there is no definitive diagnosis. If the patient's history notes a family history or

personal history of colonic malignancy or polyps, the above appropriate V- should be

assigned as a secondary code.

Digestive Disease

Condition ICD-9-CM

Codes ICD-9-CM Code

555.0

555.1

555.2

555.9

556.0

556.1

556.2

556.3

556.8

556.9

558.2

558.9

ICD-9-CM Code Descriptor

Regional enteritis of small intestine

Regional enteritis of large intestine

Regional enteritis of small intestine with large

intestine

Regional enteritis of unspecified site

Ulcerative (chronic) enterocolitis

Ulcerative (chronic) ileocolitis

Ulcerative (chronic) proctitis

Ulcerative (chronic) proctosigmoiditis

Other ulcerative colitis

Ulcerative colitis, unspecified

Toxic gastroenteritis and colitis

Other and unspecified non infectious

gastroenteritis and colitis

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Pap Test

Medicare provides coverage of a screening Pap test for all female beneficiaries once every 12

months if a) there has been evidence of cervical or vaginal cancer or other abnormalities during

any of the preceding 3 years or b) is considered high risk. Coverage is provided every 24 months

for low risk female beneficiaries.

Diagnosis Requirements

Use one of the screening ("V") diagnosis codes listed below. Code selection depends on whether

the beneficiary is classified as low risk or high risk. This diagnosis code, along with other

applicable diagnosis codes, must also be reported. Failure to report the V76.2, V76.47,

V76.49, or V15.89 diagnosis code will result in denial of the claim.

Diagnosis Codes

V76.2

V76.47

V76.49

V15.89

ICD-9-CM Code Descriptor

Special screening for malignant neoplasms; Cervix;

Routine cervical Papanicolaou smear. Excludes: that

as part of a general gynecological examination

(V72.3)

Special screening for malignant neoplasms; Other

sites; Vagina; Vaginal pap smear status-post

hysterectomy for non-malignant condition. Use

additional code to identify acquired absence of uterus

(V45.77). Excludes: vaginal pap-smear status-post

hysterectomy for malignant condition (V67.01)

Special screening for malignant neoplasms; Other

sites.

Other personal history presenting hazards to health;

Other specified personal history presenting hazards to

health; Other.

The above information, as well as more information about other screening/preventative

procedures is available by downloading The Guide to Medicare Preventive

Services for Physicians, Providers, Suppliers, and Other Health Care

Professionals.

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